section two

This page forms part of the Transcultural Health resource, published in 2004, and is preserved as a historical document for reference purposes only. Some information contained within it may no longer refer to current practice. More information

Identity is a socially constructed phenomenon. That is, our idea of ourselves, definition of self, and what to do, depends on a 'feedback loop' between our action in the world and our reflection upon it. Therefore, as Peter Hartley suggests (1993:108), social identity is constructed from three elements:

personality;
self concept; and
role.

For example: You may consider yourself to be a friendly, sympathetic, open person, always willing to lend a hand in a team context - this is your personality. Perhaps in the clinical setting, you occupy a substantial professional position which bestows upon you status, and justifiable pride - your self-concept and role.

Personality

According to Hartley (1993), there are three main principles that define the personality:

Each of us has a specific set of personal characteristics.
This set of characteristics is fairly stable over time.
These characteristics influence how we behave and communicate. (Hartley 1993:109)

We are all familiar with the everyday usage of the idea of personality. We say someone is aggressive, that someone else is timid or that some other person is sociable. Behind all these statements is a common belief that people have stable ways of being, feeling and acting which is characteristic of them. Or again, when we say that someone's behaviour was 'not in character' we are asserting that there is a more usual consistency underlying their behaviour.

A belief in 'personality types' is very convenient for our attempts to make sense of other people for it condenses a great deal of potential information into relatively simple labels. Indeed, in the psychological literature there are sources that argue strongly for such powerful fundamental organising principles in peoples' lives. (Hans Eysenck, for example, was a vociferous exponent of this view.) However, contemporary social psychology emphasises the flexibility and situational determination of human behaviour.

But, we are familiar with the fact that people possess different styles in the way in which they fulfil their roles. They bring a personal agenda to the normative expectations of the context. In this we can detect a degree of consistency in people's behaviour. The implications of this are at least twofold: we need to be prepared to treat people differently as they fulfil the same role, and: we need some accuracy in identifying their particular style.

The concept of a trait that can be found in the psychological literature can help us to have a sense of how we develop individual behavioural routines.

The concept of trait can be used to usefully remind us that we develop individually characteristic ways of responding to our environment. Learned routines of feeling, belief and action facilitate our rapid negotiation of our environment by providing a repertoire of responses with which we are comfortable. Relying on such routines can, however, also make us lazy or resistant to trying alternative strategies.

Believing that we can identify deep-seated personality types within other people, that consistently guides their behaviour, is a dangerous assumption. Particularly is this so when certain 'personality types' are seen as being characteristic of whole groups of people. The gross labelling of ethnic communities as having distinct personality syndromes has been a distressing expression of racism within health care (Robinson, 1995, Fernando, 1991).

Perhaps it is appropriate to train ourselves to be sceptical about giving too much weight to 'personality' as a route to understanding others. It tempts us into explaining too much on the basis of too little.

Hartley sums up his own view thus:

We do possess a range of traits.
These traits do influence how we behave and communicate.
These traits are only one influence upon our behaviour.

(Hartley, 1993 p. 110)

Self concept

Uniquely, the human species has the capacity to reflect on its' actions, opinions and decisions. 'I' can consider my 'self'. A part of us is capable of 'standing back' and reflecting on what we have done, where we are now, and where we might want to be in the future. Thus, we are capable of forming a self-concept, which is the sense of the self, enduring over time.

We perhaps feel this most when we are deeply involved in one activity, like driving, but are transported elsewhere to a memory of our last holiday. One part of us is performing with the necessary awareness of the immediate environment, and the other is sitting on a beach in the sunshine - reflecting on a past action/self. You may in this case be recouping self-esteem from memories because you just had a stressful shift in which you felt put-upon by patients and other staff. In order to maintain a healthy self-concept we must maintain self-esteem from the reference groups to which we belong. Our self-concept helps us prioritise the information in the world which is of most relevance for us, in order to maintain a reasonable degree of self-esteem, order, and integrity.

Social identity theory

Social identity theory is an influential contemporary model within social psychology. (See, for example, Hogg and Abrams 1988, Abrams and Hogg 1990.) It starts from an assertion that we are all members of very many social groups and that we find our social identities through our attempt to sustain our acceptance within them. Each group has its own norms and hence its own criteria for defining good and bad members.

At the core of social identity theory is a process of social comparison. We compare ourselves with members of the in-group (to ensure that we are like the others); and with members of out-groups (to ensure that we would not be mistaken for one of them). This social comparison, however, is not random. The criteria for comparison are those values and practices that are of importance to the group. Each group has its own rules about how we recognise each other as members of the in-group.

See the discussion of boundary maintenance in relation to ethnicity in the companion module, The Politics of Diversity by Charles Husband.

Thus, we seek to measure ourselves and others in relation to the criteria that define in-group membership: being calm may be a relevant criteria for colleagues in an Accident and Emergency team, but not at all appropriate in a group of football fans. Consequently, these criterial attributes mean that we make very selective judgements about our behaviour depending upon which membership group, that is, which social identity, we are currently negotiating. The importance of the social psychology of social identity theory is the emphasis it places on our emotional attachment to particular groups. Our important social identities are not just roles we happen to fulfil; they are emotionally meaningful attachments to social groups.

The process of social comparison is not some kind of neutral account keeping. It is important to us that the feedback we get from social comparison makes us feel good about our membership of the group. Thus, in our acts of social comparison we strive to maintain positive self-esteem. Consequently, sustaining our social identities takes place through an active negotiation with our personal identity. This personal identity is the biographical, existential self that has been the continuing presence within all of our acts of social identity. It is the ongoing identity which we seek to maintain as a coherent core in our lives.

By locating us within specific social groups, in which we have particular statuses and fulfil designated roles, social identity theory draws together the issues of norms, self-concept and identity that we have discussed above. It confirms our understanding of the social foundations of our identity. It shows how our social identities interact with our personal identity.

Our social identities result from the categorisation of the world into in-group and out-group and the labelling of oneself as a member of the in-group. Thus, the language we use is very powerful in providing the categories that we employ. In Britain, we are very comfortable with bi-polar categories: good-bad, young-old, male-female, or black-white. This type of categorisation suggests that there are distinct boundaries between members of the in-group and members of the out-group. The social psychology of this process tends to exaggerate the difference of the in-group from all members of the out-group.

Given the potential power of this process, how we label people is very important. There is a danger of the self-fulfilling prophecy. Nurses are familiar with the distinction between a 'good patient' and a 'bad patient'. Once labelled as a bad patient, nurses are likely to approach that person with a very selective view of their behaviour. The labels we have available to us are socially constructed, and often presented to us via the media. Categorising someone as a 'new neighbour' could have many different consequences from choosing to label a new arrival as an 'immigrant'. For example, at present the Government is trying to construct an absolute distinction between an 'economic migrant' and a 'real asylum seeker'. The former can be easily rejected whilst the latter demand our sympathy.

Our social identities, sustained through our participation in different groups, have importance for us precisely because they are more than just learned roles we perform. We do not just act out our roles, we express ourselves through them. In living our social identities we bring meaning to our lives. Thus, our social identities define group relations in which we each find individual value. Consequently, social identity theory stresses the interactions between our unique personal identity and our many social identities. We may be members of social groups, but we negotiate our social identities in relation to our personal identity.

Thus, the pursuit of positive self esteem through social comparison necessarily involves the interplay of the specific social identity and the enduring dynamics of our personal identity. It therefore becomes clear that fulfilling social roles requires much more than simply applying learned behavioural responses to social stimuli in different contexts. Fulfilling social roles always requires a dynamic engagement of the personal identity in making the social identity meaningful. Not only do nurses seek to deliver holistic individualised care; they are also holistic unique persons.

Professional education, and socialisation in the practice setting, seeks to routinise the social identity of 'nurse'. But, each nurse experiences the satisfactions and distress of nursing in relation to the dynamic tension between their personal identity and social identity as they engage in social comparison within their practice setting. In interpersonal comparison with other nurses it matters that a nurse can feel good about their practice. Where the resources available compromise a team's ability to deliver high quality care the team tends to develop strategies to manage the stresses resulting from the gap between their professional values and the realities of their practice. Often over time, to remain a valued member of the team an individual must remain silent about their collusion with poor practices. The shared strategies of emotional labour that enable the team to survive requires an acceptance of collective norms: if you are to remain a valued 'one of us'.

Social identity theory provides insight into how, and why, we may have strong commitments to our in-groups. It also warns us that we are capable of categorising other people as members of an out-group, and then cease treating them as a unique individual. We make an inter-group comparison between us and them; and consequently stereotype the individual as a typical 'one of them'. Such "inter-group postures" can be very damaging to intercultural communication.

Reading

A brief account of social identity theory can be found in M A Hogg and G M Vaughan (1988) Social Psychology, London: Prentice Hall, in Chapter 10 - 'Intergroup Behaviour'.
A more extensive account can be found in D Abrams and M A Hogg (1990) Social Identity Theory, London: Harvester Wheatsheaf.

Exercise 2.1 Self reflection activity

On a separate piece of paper, note down your answers to the following questions.

Which roles are representative of what we might call your social identity?
How does your personal identity impact upon the way you carry out these roles?

Communities of practice

In this section we will draw upon a recent research study carried out by the English National Board of Nursing, Midwifery and Health Visiting (ENB). This study looked at how nurses develop and sustain their professional identity, and at how this operates within the institutional context within which nursing care is delivered. It provides a powerful insight into how health care professionals struggle to sustain practice standards and retain their positive self-esteem in the context of limited resources.

You are strongly encouraged to read 'Communities of Practice and Professional identities', Chapter 5 of Burkitt, I. et al (2001) Nurse Education and Communities of practice. London: ENB.

In simple terms, a 'community of practice' is a specific workplace - that is, a specific work setting or context. In the health care field this might be a particular department in a hospital, a community mental health team, a hospice, a specialist clinic, a GP practice, an education setting, and so on.

Burkitt et al's (2001) theory is that 'communities of practice' have two major axes.

One axis is defined through a social psychological sense of identity - a consciousness of kind.
The other axis is made up of the interaction of resources, power, space and time in a specific setting - it is institutional. (2001:58)

The axes can therefore be represented as:

Burkitt et al 2001:37

(Burkitt et al 2001:37)

However, as Burkitt et al comment:

Although we will represent these axes as independent they clearly interact in shaping any nurse's experience of being a nurse. For although, as we will argue, in an important way nursing operates through the construction of shared identities which give meaning to the status of nurse, and legitimate the act of nursing: so too nursing care is delivered in a specific setting. The subjective sense of identity which frames the authenticity (Taylor 1991) of the nurse's behaviour must operate within an institutional infrastructure; that is, be determined by distant impersonal forces operating in relation to abstract managerial concepts. (2001:58)

The main tenet of this thesis is that all nurses work in environments over which they have little control since 'the physical fabric of their working context has been significantly determined by external economic parameters and health care philosophies' (2001:59) much of which contribute to 'an alienation of the human essence of caring from the process of nursing. (2001:60)

In addition:

The institutional parameters that define a community of practice provide a shared environment, a common structured world, that those working there share.

(Burkitt 2001:60)

Institutional features

Therefore, according to Burkitt et al, the institutional parameter is an important feature of a community of practice since the 'shared institutional context is one of the bases for the formation of a shared identity'. (2001:60)

The defining institutional features of communities of practice can therefore be identified as including:

shared institutional context;
shared identities (including hierarchical ordered identities among different health care professionals, e.g. doctors, nurses, pharmacists, nursing specialisms);
power relations between different health care professionals and between nurses of differing status.
the resources made available to facilitate the shared practice - the time, space and staff available in providing a service.

Indeed, as Burkitt et al comment:

It is because these patterns of power have been established over time and are routinised in the daily culture of each work place that they are part of the institutional framework of the community of practice. To the extent that these statuses and relations of power have been constructed through the formalisation and bureaucratisation of delivering care they are part of the impersonal 'iron cage' of institutional practice which define the nature and limits of nursing. (2001:61)

All nurses and health care professionals are only too aware of the ways in which the physical constraints of their work place and the stretched resources of staff and materials impact upon their experience of trying to deliver high quality health care. And within that context they are also aware of how management practices and philosophies set targets and expectations which highlight their difficulties in trying to work with limited resources whilst trying to address relentless demands for health care (see Traynor, 1999).

Consciousness of kind

Burkitt et al's point here is that nurses share a sense of identity: a sense of belonging to a 'community' of others like themselves - a consciousness of kind. And whilst no nurse will ever know every other nurse they, nonetheless, subscribe to an 'imagined community' in which there are shared characteristics, shared values and common understandings; and to which nurses are emotionally, as well as intellectually, attached.

In sum, nurses like nations inhabit a shared identity that is socially constructed and which has a continuity, partially if not entirely, expressed in the subjective values, practices, beliefs and emotional attachment, one to the other, of its members.

(Burkitt et al 2001:62)

However, as illustrated by the diagram above, the 'consciousness of kind' axis does not exist in isolation. It interacts with the 'institutional axis' in the process of shaping the environment of the community of practice. Therefore, as Burkitt et al remind us:

...a strong consciousness of kind is no guarantee of the possibility of expressing an identity in action: nor indeed of being sufficient to guarantee the survival of that identity...[So]...in exploring the practice of nursing within the particular communities of practice through which care is delivered it is important to distinguish between the subjective solidarity - the consciousness of kind - which sustains nurse identities, and the institutional structures, routines and ideologies - the infrastructure - which defines the boundaries of the possible modes of practice.

(Burkitt et al 2001:63)

Professional identities

Burkitt et al's view is that the professional socialisation of nurses has been a:

complex struggle between the humanism that informs the 'vocation' to be a nurse and the instrumental reason of health service management that seeks to provide an efficient service. (2001:64)

As a result,

The humanism at the core of the consciousness of kind of all nurses, and expressed in the generic professional ethos of 'holistic individualised care' comes into daily conflict with the pragmatic necessities of delivering care in a specific community of practice.

(Burkitt et al 2001:64)

This demonstrates, again, that the two axes of the community of practice 'not only interact; but may indeed generate contradictions and conflict' (Burkitt et al 2001:64).

In establishing their professional identity nurses are therefore required to negotiate these contradictions and conflicts - not as one 'imagined community' or shared 'consciousness of kind' but from the point of view of specific branches and specialisms - as mental health nurse, A&E team leader, palliative care nurse, or theatre sister.

The concept of community of practice is very helpful in enabling us to bring together the social psychology of professional identity with the institutional forces that shape the delivery of care. It provides a model for understanding the collective attempts to sustain a high standard of professional care. It also reveals the individual costs of trying to sustain this in the face of inadequate institutional resources.

Burkitt et al identify an 'inclusive identity' of nurse which is 'compatible with, and indeed at the core of, all nurse identities - an identity characterised by caring, compassion, empathy, controlled emotion and personal engagement with the patient (2001:66).

This inclusive, 'in group', identity of nurse is constantly contrasted with the 'out group' identities of other health care professionals, and thereby 'provides a psychologically rewarding boundary between self and others: between us and them' which seeks to provide positive feedback to self as well as an escape from the experience of feeling 'bad' or 'inferior' (Burkitt et al 2001:67).

This inclusive 'generic' identity of nurse is a powerful shared social identity. It allows nurses operating in very different contexts, and carrying out very different functions, to recognise each other as having a common identity and shared professional values. It is these core values and beliefs that all nurses can call upon in judging their own, and other nurses, competence in delivering health care. It is in relation to these values and beliefs that they measure their job satisfaction.

However, social identity dynamics do not simply apply to nurse, or 'not nurse' identities alone. Within nursing there are many branches and specialisms, and the distinctions between these provide the basis for specialist nursing identities. The ENB research reported in Burkitt et al (2001) provides powerful evidence of the importance of these specialist identities for individual nurses. A & E nurses, and 'burns nurses' and palliative care nurses share very particular working environments that are typical for their specialism. And they experience very particular health care needs from their patients. Thus these specialist identities are built out of their experience of trying to deliver quality nursing care in specific circumstances. They are not an alternative to the inclusive identity of nurse; rather they are a refinement of it.

As nurses seek to find fulfilment in their professional identity as a nurse the 'specialist nursing' identities provide quite specific institutional settings in which they can seek to balance their performance with their aspirations. Indeed as Burkitt et al (2001:66) found

...nurses themselves through job mobility and career change often actively take responsibility to find a fit between their valued community of identity and a work setting whose routines and practices are conclusive to their being able to express themselves in practice.

In other words, nurses move from workplace settings where the institutional context inhibits their ability to deliver good quality care to communities of practice where they are enabled to be 'a good nurse'.

Exercise 2.2 Self reflection activity

Can you identify your community of practice?
Do you recognise yourself as having a generic identity as 'nurse'?
Do you have a 'specialist identity'?
Reflect upon how the 'institutional axis' in your workplace impacts upon your practice.

Making the 'Normal' Routine

Much of the behaviour that goes with our fulfilling a particular role is routine: it requires little conscious thought. One may not always remember a journey home by car unless something unusual or dangerous happened. This is because one was relying on learned sequences of action most of the time: like 'seat-belt, ignition, mirror, clutch' etc. The world is such a complex place, such an endlessly buzzing city of noisy detail, that we need such cognitive strategies to make life more simple, even possible.

In nursing there are many structures and 'habits' that are important for the smooth, functional 'flowing' of any ward or clinic. These professional frameworks, or 'communities of practice' (Lave and Wenger 1991) are the normative frameworks within which hierarchies of professional priority exist. Professional socialisation aims at making the nurse consistent and unselfconscious in their practice. In a busy A & E ward, nurses do not have the time to debate who shall do what, or ask how to carry out a clinical intervention. Equally, in taking initial details from a new patient, whilst each patient is unique, there are strategies which can routinely guide individualised holistic care.

Whilst we may be able to consciously retrieve the rules that guide our behaviour, we may have much more difficulty in recognising and reflecting upon the cognitive routines that have been laid down in our practical consciousness. The integration of perceptual strategies, ways of feeling and hierarchies of available actions should warn us of how difficult it may be to acquire new knowledge and ways of practising health care delivery.

To paraphrase Argyle (1994 most social organisation is a combination of practical motor skills and social skills plus experience of their use. These components are brought together in order to meet the situational demands of a specific context. In meeting the many demands of our social world we need to maintain plasticity: that is, to be fluid, capable of change and responsive to the challenge of the new. This is never more so than in aspiring to deliver individualised holistic care in a multiethnic society.

In developing transcultural nursing competencies, we must anticipate the possibility of unlearning as being a necessary complement to knowledge acquisition. Where our routines have the positive and negative sanctions of strong communities of practice, this may not be easily achieved by a single individual. The culture of the work place provides a powerful normative framework within which transcultural practice must develop.

Authenticity in our behaviour

In talking of roles, of cognitive routines and of professional routines, there is a danger of suggesting that health and social care practitioners are merely over-trained robots. And, indeed, in a world where we are familiar with human thought processes being discussed in the language of computing and information processes, it is important to resist depicting human beings as mechanistic data processing machines. Indeed, a model of human beings as some kind of rational information filters, operating through rigid over-learned routines, would have little to offer nursing or social care professionals.

We have already noted how personal identities are central to our execution of the many roles we occupy. Indeed, nursing demands aspects of self which might be considered personal in other social settings, but which must be brought to bear in a caring relationship. The emotional labour so intrinsic to much nursing is indicative of this strong engagement of the personal identity in the task of nursing.

We might then ask in what ways is it reasonable to expect nurses to be flexible in fulfilling their many roles. The 'two-faced' person is generally seen as deceitful and not real. Thus, the concept of authenticity is useful in helping us to understand the personal continuity that can be found operating as a core within a wide range of behaviours.

In speaking of authenticity, Taylor (1992, p. 28) says:

"We might speak of an individualised identity, one that is particular to me, and that I discover in myself."

In seeing ourselves as "beings with inner depths" we come to have a concern with 'being true to myself'. Thus, the personal identity becomes significantly self-aware and judgmental. We have a continuing ability to monitor our behaviour against our own conception of our identity and values. When we engage in actions, which we know are inconsistent with this authentic selfhood, we seem to leak the awkwardness in intangible ways into the ambivalence of our performance.

Of course, our individualised personal identity was not developed in a vacuum; it is itself a product of our interaction in a social world. Nor can authenticity be sustained by inward navel gazing. We realise our authenticity through our interaction with others. Indeed, for nursing the idea of authenticity fits comfortably with the vocational ethos of nursing and the commitment to caring for others. Nursing techniques may change but the personal investment in caring is rooted in that enduring inner self.

This is why managerial concerns with competence and efficiency are not necessarily consistent with the nurse's commitment to caring. In the context of the current NHS it is possible to be seen as a highly professional nurse, without also feeling yourself to be a good nurse.

The philosopher Charles Taylor made the important point that this quest for authenticity is not egocentric and selfish. The continuing dialogue with our personal identity is in fact the basis for our recognition of the demands that arise from our ties with others. However, if our pursuit of authenticity is 'narcissistic' and self-obsessed, our capacity for positive feedback is diminished. We become self-referential and shallow. Taylor argued that:

The agent seeking significance in life, trying to define him - or herself meaningfully, has to exist in a horizon of important questions. That is what is self-defeating in modes of contemporary culture that concentrate on self-fulfilment in opposition to the demands of society, or nature, which shut out history and the bonds of solidarity. These self-centred 'narcissistic' forms are indeed shallow and trivialised; they are 'flattened and narrowed', as Bloom says. But this is not because they belong to the culture of authenticity. Rather it is because they fly in the face of its requirements. To shut out demands emanating beyond the self is precisely to suppress the conditions of significance, and hence to court trivialisation.

(Taylor 1991:40)

Thus, the logics of authenticity are not about being self-centred. We achieve meaning through our personal identity being engaged in addressing 'a horizon of important questions'. Yet again, our essentially social nature is underlined. At the point at which we pursue personal authenticity we open ourselves to the social world. The social identity of health and social care professionals in contemporary Britain, more than many other social identities, commits the individual to recognising the demands of others.

This essential dialogue between the inner self and the important questions of the external world raises an important question about individual nurses' development of transcultural nursing skills. If these skills are seen as that - technical competencies that can be learned - it is not clear how they fit with an authentic delivery of individualised holistic care.

If minority ethnic patients are seen as a nuisance and over-demanding; and as ungrateful immigrants, then the legitimacy of their cultural needs can hardly be recognised. And, particularly if a carer is ethnocentric or holds racist assumptions about minority ethnic clients, the basis for respect and care cannot be present in their practice.

Transcultural practice must have a resonance with the core inner self. Transcultural competence demands an honest engagement with the values and assumptions of equal opportunities and multiculturalism. It cannot 'authentically' be 'stitched on' as a set of technical skills. (See the Module: The Politics of Diversity by Charles Husband.)

Importantly, we negotiate the tension between personal and professional identities in very specific settings. As we have seen above norms are socially constructed. But this context is not random; it is highly structured and typically has quite specific institutional forms with rules and systems of practice.

Schools of nursing in Universities and clinical settings are exactly such spaces. Consequently before we proceed any further it is important to pause and reflect on the interaction of our subjective identities and the institutional context in which we operate.

Exercise 2.3 Activity and discussion

How do professional nurses negotiate their identities within the constraints of the institutional context?
How is the concept of authenticity relevant to this process?

Exercise 2.4 Group activity

Discuss your community of practice. Identify the elements of the subjective and institutional axes. Try to identify how the workplace culture has tried to manage the tensions between these elements.